Long Term Care Application "*" indicates required fields Step 1 of 8 12% PERSONAL INFORMATIONFirst Name* Middle Name Last Name* Email Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home Number* Cell Number Date of Birth* MM slash DD slash YYYY Have you served in the U.S. armed forces?* Yes No If Yes, provide Years of Service:From To Are you a U.S. citizen?* Yes No Sex* Male Female Marital Status* Married Single Widowed Divorced Separated Name of Spouse Religion Highest Level of Education Occupation Hobbies or Club Associations Year Retired FINANCIAL MANAGER PLEASE STATE THE NAME(S) OF ANY PERSON(S) THAT HANDLE FINANCIAL MATTERSName Relationship Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home Phone Mobile Phone Work Phone Is there a Power of Attorney? Yes No Please provide their name PhoneUpload a copy of the power of attorney here Drop files here or Select files Max. file size: 512 MB. Please check type of authority Representative Payee Conservator Legal Guardian Durable Power of Attorney Type: Irrevocable Trust/Bank Account Yes No Funeral Home Contact Name Address Phone HEALTH CARE PROXY Please upload a copy hereMax. file size: 512 MB.Name Phone Relationship Address Is there a Legal Guardian Yes No Name of Legal Guardian Spokesperson for the ApplicantName Phone Emergency Contact 1 Name Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Relationship Cell Phone Home Phone Add an Emergency Contact Here Health Insurance and Income Medicare # Type of Medicare Part A Part B Part D Part A&B Other Health Insurance You May Have Please Provide a Copy of Your Insurance Card with this ApplicationMax. file size: 512 MB.Name Policy Number Are the Premiums Quarterly or Monthly? Monthly Quarterly Amount Social Security Recipient Name Monthly Income Retirement (Pension)Recipient Name Monthly Income VA PensionRecipient Name Monthly Income Rental IncomesRecipient Name Monthly Income AnnuitiesRecipient Name Monthly Income OtherName Recipient Name Monthly Income Please Note: If you are Applying for Mass health (Medicaid), The look back period is 5 (five) years. This is to determine whether there have been any disqualifying assets transfers. Bank Accounts Bank Name Account # Names on the Account Type Balance Add Another Bank Account Here Life Insurance Policy 1 Company Name Beneficiary Policy # Face Value Add Another Insurance Plan Here Current Living SituationDoes the Applicant Live Alone?* Yes No With Whom Do They Live? Address Contact Person Telephone # Physician Telephone # Does the Applicant Need Help? (Check All that Apply)* Eating Bathing Getting Dressed Does not Need Help Does the Applicant have memory loss?* Yes No What kind? Short Team Long Term Both Does the Applicant Walk? (Check All that Apply)* Independent Uses Cane Uses Wheelchair Is the Applicant Incontinent? (Check All that Apply)* Bladder Bowel Not Incontinent Has the Applicant been diagnosed With Alzhimer's/Dementia?* Yes No Does the Applicant Have Any Behaviors that Are of Concern?* Yes No Please List Them Here Applicant's Physician* Address* Telephone #* Has the Applicant Been Hospitalized Recently?* Yes No Hospital Approx. Date MM slash DD slash YYYY Please Provide Date of Last Physical Exam MM slash DD slash YYYY Has Applicant Ever Been Admitted To A Nursing Home?* Yes No Name Address Date MM slash DD slash YYYY Has Applicant Ever Been Admitted To A State Hospital or Psychiatric Unit?* Yes No Name Address Date MM slash DD slash YYYY Alcohol and Tobacco Usage Alcohol Use* Yes No How often? Past Present Past and Present Tobacco Use* Yes No How often? Past Present Past and Present Application Completed By* Date* MM slash DD slash YYYY CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
